（骨科-微创-课件）微创经椎间孔入路腰椎体间融合术.ppt

1、 Minimally Invasive Transforaminal Lumbar Interbody Fusion(TLIF)DR SEANG-BENG TANHEAD,DEPT OF ORTHOPAEDICSDIRECTOR,SPINE SERVICESINGAPORE GENERAL HOSPITAL微创经椎间孔入路腰椎体间融合术 新加坡中央医院Aim of MIS微创的目的Accomplish surgical goals through small incisions and minimal disruption of normal tissues以小切口达到手术的目的，并对正常组织

2、造成最少的伤害。Principles of Minimally Invasive Spinal Surgery微创脊椎手术的原则 Decompress and stabilize the spine Reduce the“surgical injury”to normal tissues Limit retraction of muscle 减压并保持脊椎稳定 减少对正常组织的伤害 减少对肌肉的拉扯 Reduce blood loss Improve recovery by reducing post operative pain 减少失血量 减轻术后疼痛，以使病人尽快康复。Principle

3、s of Minimally Invasive Spinal Surgery微创脊椎手术的原则New Advances in TLIF经椎间孔入路腰椎体间融合术的最新动向 Percutaneous decompression and cage placement with Pipeline and other tube systems Percutaneous pedicle screw fixation using Viper,Sextant,Pathfinder 经皮穿刺减压和利用工作通道来放置椎间融合器 利用Viper,Sextant,Pathfinder，经皮植入椎弓根螺钉。Strat

4、egies to Avoid Complications with MIS微创手术中减少并发症的策略 Training 培训 Patient selection 选择适当的病人 Setup 设备 Access 入路 Pedicle screw placement 椎弓根螺钉的植入 Misc 其他策略Training培训THERE IS A LEARNING CURVE!学习的过程 Cadaver workshops View cases with surgeon well trained in applying these techniques Start slowly and work up

5、 to more complex cases 在尸体上练习 在熟练医生进行这类手术时观摩 循序渐进，慢慢地过渡到复杂的手术。Training培训 Start big and move smaller-gradually reduce incision size Start in the lumbar spine Become comfortable with microdiscectomy first Learn kyphoplasty 由大的切口开始，慢慢地缩小切口 由腰椎开始 先从熟悉显微椎间盘切除术入手 学习球囊扩张椎体后凸成形术Patient Selection选择适当的病人 MIS

6、fusion patients primarily one segment disease DDD some disc space preservation Grade 1 to low Grade 2 spondylolisthesis Beware of L5-S1(sacrum sometime hard to visualize pedicle screw targeting)微创融合术的病人 由单间隙的病患开始 椎间盘退化-椎间距离不宜太小 第一级的腰椎滑脱或轻微第二级的腰椎滑脱 小心L5-S1间隙（在骶骨植入椎弓根螺钉会比较困难）Start with relatively thin

7、 individuals with good bone quality Obesity and osteoporosis difficult to visualize bony anatomy adequately 从骨质相对比较好和较廋的病人开始 肥胖和骨质疏松症 使骨骼较难充分暴露Patient Selection选择适当的病人TLIF Access椎间融合器入路Working Zone操作区域Access osteotomy入路截骨Decompress the ipsilateral side,then put in the largest cage,before decompressi

8、ng contralateral side.同侧减压先。然后，在另一侧减压前，植入最大的椎间融合器。Nerve神经Pedicle screw placement植入椎弓根螺钉Percutaneous Screw Angulation经皮调整螺钉的角度MOVE LATERAL!向外侧移动！Starting Point起点Pedicle Mid Point植入椎弓中途Thru the Pedicle完全植入Ensure screw heads are at the same level螺钉头要固定在同一水平线上微创和开放性经椎间孔入路腰椎体间融合术的6个月与2年随访调查Spine Service,

9、Orthopaedic SurgerySingapore General Hospital脊椎专科，矫形外科新加坡中央医院Prospective Trial of MIS TLIF Vs OPEN TLIF 6 Months&2years Result MIS微创OPEN 开放型Age 年龄(years)58.458.5Sex 性别(F:M)(女:男)116:6512:3Fluoroscopy time透视时间1min 45 secs35 secsDuration of Surgery 手术时间（小时）3:19(range:2:15 4:40)2:40(range:2 3:55)Blood l

10、oss失血量 200ml500ml MIS微创OPEN开放性Length of hospitalisation(days)住院时间（天）4.4(range:2 9)6.0(range:5-7)VAS:POD/DISCHARGE视觉模拟疼痛评分：术后/出院5.0/1.06.0/2.6Total Morphine(PCA,mg)吗啡(止痛药）剂量17.435.7Ambulation:Room/Ward(POD)术后第几天开始步行1.0/2.03/4North American Spine ScoreBack Pain&Disability Score北美脊椎协会评分标准北美脊椎协会评分标准 疼痛及

11、残疾指数疼痛及残疾指数BACK PAIN&DISABILITY(Range 0 to 100)0=No back pain or disability100=Maximum back pain or disability疼痛及残疾指数(0 至 100分)0=没有疼痛或残疾100=非常疼痛或极度残疾开放性开放性微创微创术前术前术后六个月术后六个月术后两年术后两年North American Spine ScoreNeurogenic Symptom Score北美脊椎协会评分标准北美脊椎协会评分标准 神经性症状指数神经性症状指数NEUROGENIC SYMPTOMS(Range 0 to 100

12、)0=No neurogenic symptoms100=Severe neurogenic symptoms开放性开放性微创微创术前术前术后六个月术后六个月神经性症状指数(0 至 100分)0=没有神经性症状100=极度神经性症状术后两年术后两年North American Spine Score(6mths)北美脊椎协会评分标准北美脊椎协会评分标准 到现在为止到现在为止,手术符合你的要求吗手术符合你的要求吗?(术后六个月术后六个月)开放性开放性微创微创符合符合多多少少多多少少不符合不符合North American Spine Score(2yrs)北美脊椎协会评分标准北美脊椎协会评分标准

13、 到现在为止到现在为止,手术符合你的要求吗手术符合你的要求吗?(术后两年术后两年)开放性开放性微创微创符合符合多多少少多多少少不符合不符合North American Spine Score(6mths)北美脊椎协会评分标准北美脊椎协会评分标准 你怎样评价手术对治疗你的腿或背痛的疗效你怎样评价手术对治疗你的腿或背痛的疗效?(术后六个月术后六个月)开放性开放性微创微创优优中中差差North American Spine Score(2yrs)北美脊椎协会评分标准北美脊椎协会评分标准 你怎样评价手术对治疗你的腿或背痛的疗效你怎样评价手术对治疗你的腿或背痛的疗效?(术后两年术后两年)开放性开放性微创

14、微创优优中中差差North American Spine Score Return to Full Function北美脊椎协会评分标准北美脊椎协会评分标准 病人恢复工作能力病人恢复工作能力开放性开放性微创微创术后六个月术后六个月术后两年术后两年Visual Analogue Pain Scale Back pain视觉模拟疼痛评分视觉模拟疼痛评分 背痛背痛开放性开放性微创微创术前术前术后六个月术后六个月平平均均分分数数术后两年术后两年Visual Analogue Pain Scale Leg pain视觉模拟疼痛评分视觉模拟疼痛评分 腿痛腿痛开放性开放性微创微创术前术前术后六个月术后六个月平平均均分分数数术后两年术后两年